NIIEN Form

Notification of Illness, Injury, Exposure & Near Miss Form

In the event of something untoward happening at work (or directly related with work) to a member of staff or a customer (either illness, accident, exposure or a near miss), we are required by law to keep a record of the incident and, in more serious cases involving a threat to life or serious injury, report directly to the regulatory authorities (Safe Work Australia being a first point of contact).

* Indicates required field

Name of attending supervisor completing this form *

First

Last

Date dd/mm/yyyy *

Injured affected person *

Employee Guest Other

Incident *

Injury Illlness Exposure Near miss

Treatment or ambulance required *

Yes No

Witness 1 *

Witness 2 *

Witness 3 *

Name of affected party *

First

Last

Phone Number *

Address - line 1 *

Address - line 2 *

State *

Post code *

What is the injury, illness, exposure or near miss? *

Describe how and where the injury, illness, exposure or near miss occurred *

Possible preventative action including isolation of area and machinery implicated in the incident *

Submit